创新药保障“最后一公里”待解

Core Insights - The release of the new National Medical Insurance Directory and the first Commercial Health Insurance Innovative Drug Directory marks a significant shift in China's healthcare system towards a dual-driven model of "basic medical insurance + commercial health insurance" [1][2] Group 1: Policy Changes - The new directories will be implemented on January 1, 2026, and represent a milestone in establishing a multi-tiered medical insurance system in China [2] - The Commercial Health Insurance Innovative Drug Directory provides a high-quality "drug pool" for insurance companies, reducing the barriers for product development and information asymmetry [2][3] - The basic medical insurance directory has added 114 new drugs, achieving a negotiation success rate of 88.19%, the highest in seven years, enhancing drug coverage in critical areas [3][4] Group 2: Drug Inclusion and Coverage - The first Commercial Health Insurance Innovative Drug Directory includes 19 drugs, focusing on high-value innovative treatments that exceed basic insurance coverage, such as CAR-T therapies and Alzheimer's drugs [4][5] - Five CAR-T therapies have been included in the directory, representing over half of the currently available products in China, with prices exceeding 1 million yuan for most [5][6] - The directory also includes treatments for rare diseases, demonstrating a commitment to vulnerable populations [6] Group 3: Market Dynamics - The dual-directory system is designed to address the structural challenges of high-value innovative drugs, allowing commercial insurance to cover these costs before they are potentially included in basic insurance [7][8] - The introduction of commercial insurance funding is expected to enhance the clinical drug level and overall R&D return rates for leading innovative pharmaceutical companies [6][11] Group 4: Consumer Impact - The new payment structure allows patients to access innovative therapies without facing the dilemma of full out-of-pocket costs, as commercial insurance will provide support [8][9] - The expansion of special drug lists in commercial insurance products is becoming a trend, with many regions updating their offerings to include high-value cancer and rare disease medications [9][10] - However, challenges remain in ensuring that hospitals stock these high-cost drugs and that the claims process is efficient and transparent [10]